Chest pain

Pain in the chest is a common complaint that has many causes, ranging from mild causes such as muscle strain, to serious causes, such as cardiovascular problems including heart attack. Due to the complexity of the nervous system, chest pain may also be caused by problems elsewhere in the body, such as the abdomen. If you have chest pain, it is often best to treat it as serious and seek immediate medical attention.

There are many causes of chest pain, such as muscle strain and heart problems. 

Causes

Many organs are contained within the chest. This means that there are many different causes of chest pain.

Muscles and bones

A common source of chest pain are the joints that connect the ribs to the breastbone. Inflammation can occur at these joints and it is named costochondritis. The hallmark feature of this condition is that the pain can be reproduced by pressing over the point of inflammation.

Other conditions that affect the musculoskeletal system, such as fibromyalgia and rheumatoid arthritis, can also cause chest pain.

Heart and blood vessels

Heart attack

It is difficult to distinguish pain caused by a heart attack from pain caused by something less serious. That is why it is important to always seek medical attention if you experience chest pain.

It is more likely that you have experienced a heart attack if:

• You experience chest pain, pressure, burning or tightening in the chest;
• The pain is typically over a wide area, including the middle of the chest, and extends to the jaw, neck, or back, and;
• You have difficulty breathing, a cold sweat, or sudden feeling of nausea.

Angina

Angina is the pain that occurs when there is poor blood flow to the heart muscle. It is often caused by atherosclerosis, which is when plaques made mainly of fat and cholesterol build up on the lining of blood vessels and cause them to harden and narrow. In stable angina there is a known trigger and it is responsive to treatment. In unstable angina the attacks are unpredictable, causes are not obvious and/or the pain occurs at rest with minimal exertion.

Heart failure

If the heart is unable to pump enough blood, blood can accumulate in the lungs, causing fluid to leak into the airways. This is known as heart failure and can cause difficulties in breathing, coughing and also chest pain.

Pericarditis

The inflammation of the sac surrounding the heart (pericardium) is known as pericarditis. The pain of pericarditis is often made better by leaning forward. Pericarditis has many causes, including infection, radiation, rheumatic diseases, physical trauma and unknown causes.

Aortic dissection

Aortic dissection is a rare but serious condition. It occurs when the inner layer of the aorta tears, leading to blood flowing between the layers. This can cause reduced blood flow to the rest of the body and/or risk of the aorta rupturing. Pain associated with aortic dissection is severe, sudden and typically felt between the shoulder blades in the back.

Lungs and airways

Pulmonary embolism

Pulmonary embolism occurs when a blood clot is dislodged from the wall of a vein and travels to the lung. This blocks blood flow to part of the lung and limits gas exchange needed to allow oxygen to reach your body's cells. If the outer lining of the lung is involved, you may experience a stabbing chest pain when taking a deep breath. The blood clot in the vein may also cause swelling of a thigh or calf.

Pneumothorax

Pneumothorax is a collapsed lung. This allows air to build up between the chest wall and lung. This can be due to an injury where a rib is broken that then damages the lung, resulting in a pneumothorax. A pneumothorax can also occur spontaneously with no obvious trigger. This most commonly occurs in young men who are tall and slender.

Pneumonia

Pneumonia is an infection of the lung. The lung itself has no pain sensation but the linings on the outside of the lung can become inflamed if the infection is close. This can cause pain that is often worse when you inhale. Pneumonia often also causes a fever and coughing.

Esophagus and stomach

Esophageal spasm

When the muscles in the esophagus spasm, it can cause severe chest pain. This was previously a common label given to chest pain that was severe but not a heart attack. However, research suggests that this is an uncommon cause of chest pain.

Heartburn

Heartburn, also known as gastro-esophageal reflux disease (GORD), is the reflux of stomach acid back into the esophagus. This can be painful in the chest area.

Perforated peptic ulcer

Perforation of peptic ulcers is when they cause a hole in the wall of stomach. This results in a rapid heartbeat and sudden, severe pain that may radiate to the shoulders.

Psychological causes

Hyperventilation that accompanies panic attacks can cause chest pain. This pain can be so severe that you might think you are having a heart attack.

Other causes

Shingles

A common site for shingles is a band around the chest roughly at the level of the armpit. It can cause chest pain before a rash becomes noticeable and the pain can be severe.

Trauma or neoplasms

Physical trauma or tumors can exert mechanical pressure in the chest that causes pain.

Tests for chest pain

Chest X-ray

X-rays use ionizing radiation to create an image of your body's internal structures. A chest X-ray can look at the lung for evidence of pneumonia or pneumothorax and can look at features of the heart and aorta.

Troponin test

Troponin is a protein found in heart muscle and skeletal muscle. Damage to heart muscle from a heart attack causes heart cells to die and release troponin into the bloodstream. The greater the damage, then the greater the troponin levels. Multiple blood samples will be taken for testing to see how troponin levels change over time.

Full blood count

A full blood count, also known as a complete blood count, will be used to look for signs of infection.

Arterial blood gases

Arterial blood gases assess how well oxygen and carbon dioxide are being exchanged in your lungs. This can be used to determine how bad pneumonia, pulmonary embolism and pulmonary edema are.

Endoscopy

During an endoscopy you'll be sedated and a long narrow telescopic camera will be inserted down your throat so the digestive system can be seen. This will be done to confirm esophagitis, when the cause of chest pain is not clear.

Electrocardiography

The beat of your heart is caused by coordinated electrical currents through its cells. During electrocardiography, or an ECG, electrodes are attached to your chest while you lie on your back. These record your heart's electrical activity from different angles. This test determines if there are any abnormalities in your heart rhythm. To see how your heart responds to stress, the test can be performed while you jog on a treadmill.

An electrocardiogram can be used to look at your heart's rhythm. 

Echocardiography

Echocardiography uses ultrasound waves to create an image of the heart. It allows your doctor to see the size of your heart and how well it is working by showing how hard it is pumping blood, whether the valves are leaking, and highlighting areas of damage caused by a heart attack or something else. To determine how the heart is working under stress, this test can be performed after exercise.

When to seek medical attention

Chest pain will often resolve itself after a few minutes. However, it is important to seek medical attention if you experience chest pain, because if the cause of the pain is cardiovascular, delaying treatment may put your life at risk.